Approval of an inter-institutional training program for liver transplant surgeons, pathologists, and recipient transplant coordinators (RTC) was applied for by the Kumamoto University Hospital from the Ministry of Education, Culture, Sports, Science, and Technology (MEXT) in Japan in 2014. It was fortunately adopted, and operated with the financial support of MEXT in the first 5 years, and by Kumamoto University Hospital in the following 2 years. The program was operated by cooperation of six National Universities (Kumamoto, Nagasaki, Okayama, Kanazawa, Chiba, and Niigata) assisted by two high-volume centers, Kyoto University Hospital and the National Center for Child Health and Development. As the trainees, 20 surgeons, 8 pathologists and 8 RCTs were recruited among the 6 universities. The course for surgeons was a 3-year training consisting of on-site learning in the allied institutions, simulated surgery (organ harvesting and liver transplantation) using a pig, seminars by domestic and foreign experts, and on-demand web lectures. In the follow-up questionnaire of the surgical trainees, all positively evaluated the course for career advancement or improvement of surgical skills except one who quit to move to another field. The program motivated three surgical trainees to study abroad in the transplantation field. The one-year course for pathology in liver transplantation consisted of web discussion and diagnosis of clinical cases via a virtual slide system, and on-site training in Kyoto University which had accumulated many specimens. All the pathological trainees enjoyed the course because the program offered an extraordinary chance of clinical learning that was impossible for them to have only in their own institutions. It was difficult to recruit trainees for the RCT course because the nurses in the university hospitals were too busy to undergo the training as “extra” work. A full-time post for RCT is limited in the university hospitals, and it was achieved only for 2 trainees. However, the program could enlarge the reserve group for the next generation.

Liver transplantation involves only a small community of surgeons, clinical pathologists and nurses. This inter-institutional program not only assisted the improvement of skill and knowledge of each individual but also could create a wider community as the buffer for the reserve of the professionals and the system for easier exchange of information and problems. The present program could be the prototype of such systems in Japan, although there are so many points that should be improved. The established system with teaching materials stored in the web server can be passed on to a wider and permanent structure authorized by any academic society. We are hopeful that it can offer a platform of study and official confirmation of the ability of young professionals in the field of liver transplantation in Japan.

Liver transplantation is a technically complex procedure requiring advanced surgical techniques, expertise, and experiences. Therefore, a structured training program should be of high importance for transplant surgeons. Herein, we present our first national training program, called the Six National University Consortium in Liver Transplant Professionals Training Program (SNUC-LT program), to train talent-proven liver transplant surgeons in Japan, focusing on experiences as a trainee. Through the SNUC-LT program, trainees can obtain abundant knowledge, extensive experiences, and advanced surgical skills, as well as develop their future career.

Few liver transplantations (LTs) are performed annually in Kanazawa University, a facility in which three young surgeons participated in a training program for liver transplant surgeons, the Six National University Consortium in Liver Transplant Professionals Training Program (SNUC-LT). Each trainee underwent training for 3 years, during which they visited academic medical centers where many LTs are performed. This increased their experience of LT and enabled them to study various surgical procedures performed by skilled liver transplant surgeons. However, because their visits to these centers were brief, they did not gain adequate experience in the ongoing postoperative management of the recipients. As to simulation training, the trainees harvested liver grafts and performed vascular anastomoses for LT using swine models. As a result, in clinical practice, two of the trainees were considered qualified to safely perform recipient operations except for hepatic artery anastomosis and biliary tract reconstruction, and entire donor operations. However, their operation times were long and they did not achieve learning curves. In conclusion, SNUC-LT is a useful program for supporting development of liver transplant surgeons in a facility in which few LTs are performed.

The SNUC-LT (Six National University Consortium in Liver Transplant) is original program in which systematical training and fostering of “young unexperienced transplant surgeons,” can be carried out by setting their course hours. It was also a novel approach to train transplant pathologists and coordinators, who are essential and in short supply in the LT team. For the pathologist training, we established a web-based pathology review system that allows real-time discussion and practice even at remote facilities using telepathology. We believe that SNUC-LT program in fostering transplant pathologists have achieved a certain degree of success.

In Japan, there has been a confirmation system for a registered recipient transplant coordinator (RTC) since 2011. However, a systematic educational system for RCTs has not been established yet. An inter-institutional training program for RCTs among a limited number of University hospitals was made and conducted with the aid of financial support by the Ministry of Education, Culture, Sports, Science, and Technology (MEXT) from 2014 to 2019. It was a part of the whole program applied by the Kumamoto University Hospital to train liver transplant professionals including surgeons and pathologists. In total, eight trainees, who were all active registered nurses in the university hospitals, enrolled to the program. The curriculum was set as one year for each trainee, and consisted of lectures, web conferences, and on-site learning among the different institutions. Some lectures were held combined with the congress of related academic societies to save the time for learning.

It was hard to recruit the trainees because the program had no incentives and no official confirmation for the completion of the program. However, this program could enhance the motivation of not only each trainee but also the currently working RCTs in charge of instruction. On-site training in different institutions was effective to realize the practice, and also could build an inter-institutional community of RCTs and trainees, or future RCTs. This first trial to make such an educational system for RCTs in Japan was introduced in the Congress of the Asian Society of Transplantation in 2017.

In conclusion, this prototype of a training system for RCTs in Japan was effective to increase reserves for the next generation concurrent with the formation of an intimate communication system. However, a more strict and permanent system is necessary to create more standardized qualified RCTs authorized with an official or public confirmation.

We set up an HLA laboratory in 2016 to enhance the kidney transplant medical system. In order to set up the HLA laboratory, it was essential for us to secure staff, purchase expensive equipment and acquire testing techniques. The staff were also allowed to work in conjunction with blood transfusion and to purchase the equipment by conducting tests other than HLA tests. The testing technique was acquired under practical instruction from a nearby HLA testing laboratory. The establishment of an HLA laboratory has had several positive effects. Compared to outsourcing, wait time for the test results was minimized and several processes were omitted. By joining the kidney transplant team and sharing information, we could provide more efficient blood transfusions as well as HLA testing. Furthermore, we are able to meet the needs for HLA tests for multiple medical departments and the HLA antibody tests after transplantation can be calculated as medical expenses.

However, we have multiple challenges. HLA antibody tests after transplantation increased the number of HLA antibody positive cases. Even if donor-specific HLA antibodies (DSA) are detected, kidney function is often normal, and we want to add a reagent capable of detecting complement binding to lead to early detection of antibody-mediated rejection (AMR). In addition, we must consider automatic testing techniques to prepare for future increases in the number of tests. We need to enhance the test content and aim to update the operation of the laboratory accordingly.

【Objective】 The donor factors and enzymes for islet isolation can exert a significant influence on the islet isolation results. Until 2007, Liberase HI was used as the enzyme for clinical islet isolation; however, since the islet transplant clinical trial started in 2012, Liberase MTF has been used. Moreover, since 2013, islet transplantation from donors after brain death (DBD) has been started. Here, we examined the effects of donor factors and enzymes on results of clinical islet isolation.

【Design】 Retrospective case series.

【Methods】 We compared the donor factors and islet isolation results of the two groups at our institution; the early group had 25 cases from January 2004 to July 2007, and the late group had 13 cases from July 2013 to November 2018.

【Results】 In the early group, the donations were only obtained from donors following cardiac death. However, in the late group, the donations were mainly from DBD. Owing to changes in donor background, the cold ischemic time was significantly longer in the late group (284.6±86.1 min vs. 386.9±89.1 min, p<0.005). Upon comparison of the islet isolation results, no significant difference was observed in the digestion time (21.2±6.9 min vs. 18.7±6.4 min, p=0.25) or IEQ/g pancreas after purification (4.76±2.51 vs. 3.83±1.08<×10³>), p=0.22) ; 20 of the 25 patients in HI group and 11 of the 13 patients in the MTF group met the transplantation criteria (p=0.72).

【Conclusion】 We found that the clinical islet isolation results were maintained well after the change in enzymes and change in donor background.

The expanded criteria donors (ECD) or marginal donors, including donation after cardiac death (DCD), are now accepted by most transplant centers around the world. At the same time, a greater risk of severe ischemic reperfusion injury, which may lead to delayed graft function (DGF), primary non-function, and short graft survival, has been discussed. Currently, the superiority of machine perfusion preservation is widely recognized during the preservation of kidneys, particularly those obtained from ECD and after DCD. In this study, two human kidneys that were resected because of ureteric cancer were perfused by CMP-X08, which was developed in our institution. Despite a prolonged warm ischemic time, decreased perfusion pressure and increased perfusion flow with decreasing renal resistance (RR) were seen during perfusion. However, the final RR was remarkably high. Historically, mild endothelial injury and tubular necrosis have been demonstrated. In conclusion, the safety of our newly developed machine perfusion system was confirmed. This study was approved by the Ethics Committee of Asahikawa Medical University (no.18171).

We report a patient in her 50s with uterine carcinosarcoma that occurred after renal transplantation (RTx). She had a history of right breast cancer before RTx and left breast cancer after RTx as well as uterine fibroids diagnosed by the gynecologist. Since she underwent ABO compatible live related RTx from her father her graft function had been stable with serum creatinine (Cr) of around 1.0 mg/dL. She was admitted due to acute renal failure with Cr of 8.49 mg/dL about 13 years after RTx. She was on everolimus, mycophenolate mofetil and methylprednisolone. As abdominal CT revealed severe compression of transplanted ureter due to an enlarged uterus, the ureteral stent was inserted under the cystoscope. Bladder mucosal biopsy suspected undifferentiated round-cell sarcoma. MRI and CT confirmed the invasion of the uterine tumor into the bladder as well as lymph nodes and lung metastases. A radical hysterectomy and cystectomy with ureterocutaneostomy were performed. Pathological finding revealed uterine carcinosarcoma (malignant mixed epithelial and mesenchymal tumor, carcinosarcoma, heterologous). As she developed renal failure due to residual tumor progression, it was decided not to give her follow-up chemotherapy, and she succumbed three weeks after surgery. To the best of our knowledge this is the first case of uterine carcinosarcoma after RTx. Despite close follow-up by a multidisciplinary approach it was considered that early diagnosis was extremely difficult due to rapid progression of this malignancy.